The objectives were to make recommendations for a standard method of Post-Discharge Surveillance (PDS) based on an inventory of PDS methods in hospitals participating in the PREZIES project and in foreign countries. Methods were telephone interviews on the PDS methods in the participating hospitals and a literature search on PDS methods in foreign countries. Twenty hospitals participated in the inventory, representing a response of 95%, in which the validity, efficiency and feasibility of the method were assessed. The preferred PDS method would seem to be an active system of surveillance in the outpatient clinic in which the examining specialist states in writing whether a patient has a post-operative infection or not. A good alternative is the outpatient medical record review. Checkups in the outpatient clinic about 30 days after the operation is thought preferable. SSIs occurring within 30 days of the operation are concluded to be related to the operation, except infections occurring after implantations, for which the interval is one year.<br>

In this study the prevalence of HIV among injecting drug users (IDU) in Arnhem (the Netherlands) is assessed. The results are compared with previous surveys in Arnhem in 1995 and 1991/1992. The risk of further spread among IDU, to non-IDU and to the general population is evaluated. Between October 6 and November 22 1997 a saliva specimen and a questionnaire on risk behaviour were obtained from 130 IDU in Arnhem. Participation was on a voluntary basis and anonymous. Participants were recruited through methadon care (84%), a low-treshold daytime care project (12%), a street prostitution project (2%) and from the street (2%). Of 127 IDU, only one person was infected (prevalence 0.8%, 95% confidence interval [CI] 0.0-4.3). The seroprevalence was not significantly different from the previous survey in 1995 (2.2%, 95% CI 0.6-5.5) and 1991/1992 (2.2%, 95% CI) 15% of the current IDU borrowed used syringes or needles in the last 6 months, which is much lower compared with 1995 (39%) and 1991/1992 (42%) this percentage seems to be similar in the other cities in our surveillance studies. Condom use was very low during sexual contact between steady partners 21% of the IDU have a non-drug user as steady sexual partner. In conclusion the prevalence of HIV among IDU in Arnhem in the Netherlands is O.8% and has not changed compared with surveys in 1995 and 1991/1992. Injecting risk behaviour occurs at a much lower level then in the previous surveys. Sexual risk behaviour occurs regurlarly and at a same level. The risk of further spread among IDU is low. At this level of HIV prevalence, the risk of spread to non-IDU or the general population is low.

The objectives were to evaluate the use of surveillance results in hospitals participating in the PREZIES project. Methods: a questionnaire to determine distribution and use of surveillance results, influence on policy and/or decisions on infection prevention. From the 48 contacts asked to complete the questionnaire, 79% responded. The results of the surveillance carried out in one's own hosptital were (partly) distributed in practically all cases to infection committee and to surgeons, as well as, in most cases, to nursing units and management. In comparison with the other PREZIES hospitals, the questionnaire was distributed in almost every case to the infection committee and surgeons, and less often to nursing units and management. The report on results was used in half the hospitals to provide information and, according to the contacts in all the hospitals, contributed to more awareness on infection prevention. In almost half the hospitals the results led to an intervention measure. A number of contacts in these hospitals stated that the measure led to decreased surgical site infections. In many hospitals, the time following the introduction of the intervention measure was too short to be able to assess the effect. In more than half the hospitals the surveillance supported the policy and/or decisions on infection prevention. Eighty-four per cent of the hospitals were pleased with the PREZIES project in its current form, and 89% wish to continue their participation in the national surveillance.

Data on the incidence of infectious diseases included in the Netherlands Immunisation Programme (RVP) are available at several institutes. A regular, for instance yearly analysis and reporting of these data (epidemiological surveillance), is an imported tool to evaluate the RVP. In this report information on he sources of data on the incidence of the diseases are described. The epidemiological surveillance focuses on the incidence of the disease and/or its complication(s). Mortality data provide insight into the case fatality rate, and data on the vaccination status provide insight into the vaccine efficacy. A time variable makes it possible to study trends in disease incidence. In addition to the compulsory registration of mortality at the Central Bureau of Statistics (CBS) and morbidity at the Medical Inspectorate of Health (IGZ), infectious diseases and their complications are registered at several (professional) agencies. The coverage of the registration are frequent nation-wide, for example the National Medical Registration (LMR) of the Health Care Information (SIG), the Medical-Microbiological Laboratories (MML), the Netherlands Paediatric Surveillance Unit (NSCK) and the SSPE-Registration. Sometimes registration covers a region like the European Registration of Congenital Anomalies (EUROCAT) and the Continuous Morbidity Registration Nijmegen (CMRN). Sometimes it concerns a random sampling survey like the registration of the Netherlands Institute of Primary Health Care (NIVEL). Problems can arise when comparing the data from the different institutes. It is not permissible, by legalisation, to collect data which are reducible to the name of the patient. The possibility of comparing at the level of sex, age (or year of birth), diagnosis and possibly city(region) and/or time of onset will be investigated. The registration of vaccination status is not good. Comparing the data with the Provincial Immunisation Administration (PEA) on an individual level will be difficult, but the possibility of using the PEA to obtain information on records with missing values on vaccination status must be studied.We suggest to collect data from the year 1976 onwards. The agencies can provide data on mumps, measles, rubella, diphtheria, whooping cough, tetanus, poliomyelitis, infectious caused by Haemophilus influenzae type b, strepto-, pneumo- and meningococcus (registered as main diagnosis or alternative diagnosis) stating - if available - sex, age, city(region) and/or onset of the disease and vaccination status. The epidemiological pattern of the diseases will be described on the base of the available data. The additional value of the different sources will be evaluated. On the basis of the evaluation results data will be collected and reported yearly.<br>

The objective was to obtain insight into the current incidence of pertussis. Design: Comparison study from different surveillance sources. Method: For the years 1989-1994 the incidence of pertussis was estimated from the number of pertussis notifications, from laboratory data from serodiagnosis, isolations of Bordetella and from the national registration of clinical diagnosis of hospital admissions. Results: The number of notifications and positive serological results yielded similar average annual incidence for the period 1989-1994 (2.3 and 2.2/100,000, respectively). According to notifications peak incidences occurred in 1989 (3.5/100,000) and 1994 (3.4/100,000). For positive serodiagnosis the incidences in 1989 and 1994 were 2.4/100,000 and 3.2/100,0000, respectively. In 1993 the incidence of notifications and positive serodiagnosis (2.4 and 3.2 per 100,000) was also higher than in the other years. The incidence based on hospitalizations, notifications and positive serology was highest among children younger than one year. In 1994 and 1993 the estimations for the vaccine efficacy were 84% (95%-confidence interval 80-87%) and 92% (95%-confidence interval 90-94%), respectively. Conclusion: For 1989-1994, the pattern indicated that pertussis is endemic with four-yearly peaks. The incidence of hospitalizations emphasizes the seriousness of the illness in infants. Due to the vaccine coverage in the Netherlands, the incidence among unvaccinated children is much lower then among unvaccinated children in neighbouring areas with lower vaccine coverage. It is important that general practitioners are aware of the occurrence of pertussis in vaccinated and unvaccinated children and adults. The probable decrease in vaccine efficacy (92% in 1993; 84% in 1994) needs special attention and must be monitored. This stresses the importance of continued surveillance.<br>

Polio-free certification in the framework of the global polio eradication programme, will require the implementation of a more active, comprehensive surveillance system. The Global and European Commissions for the Certification of the Eradication of Poliomyelitis have established the principles, criteria and process of polio-free certification, particularly with regard to surveillance. These include the use of performance indicators. Polio surveillance in the Netherlands should be based on the following elements. 1) Clinical surveillance consisting of mandatory notification of suspected patients and of reporting of patients with acute flaccid paralysis born in 1957 and thereafter. An expert committee has to be established for final classification of cases. 2) Virological surveillance comprising (a) diagnostic investigation of suspected polio patients and AFP patients, (b) analysis of a selection of enterovirus strains isolated in Dutch virus diagnostic laboratories, and (c) environmental surveillance. 3) Serological surveillance to determine the level of protection to poliomyelitis in the general population and specific risk groups. 4) Collection of information on vaccination coverage. The proposed surveillance system will meet the three objectives to detect possible (wild) poliovirus circulation, to determine the origin of circulating (wild) poliovirus, and to document the absence of wild poliovirus circulation in the Netherlands.<br>

The surveillance of Acute Flaccid Paralysis (AFP) is included in the Dutch Paediatric Surveillance System (NSCK) since October 1992. Paediatricians in hospitals report a list of rare diseases on a monthly basis as part of an active surveillance scheme. After the initial report, additional information on clinical presentation, diagnostic results and vaccination history is collected through a questionnaire. In 1995 11 cases conforming to the case-definition were reported, and in 1996 15, resulting in an AFP-rate of 0.39 per 100,000 in 1995 and 0.53 per 100,000 in 1996. No cases of AFP caused by polio infection were observed. In about 50% of the reported AFP cases Guillain-Barre Syndrome was diagnosed. To date, the AFP surveillance in the Netherlands does not meet the WHO criteria for adequate surveillance for certification as polio-free according to the polio eradication initiative. An observed AFP-rate of at least 1 per 100,000 is accepted as proof of sufficient sensitivity of the surveillance system. Along with timeliness of the reports, we are concerned of the low proportion of cases of whom faecal samples are adequately virologically investigated (58% one faecal sample, of which 51% within 14 days after onset of disease; 11% two samples). Recommendations for optimalisation: introducing initial reporting by telephone (immediate reporting and advice on adequate specimen collection); improved information of the paediatricians through NSCK newsletters, presentations and publications extending of the surveillance to neurologists.<br>

Risk Factors and Health in the Netherlands, a survey on Municipal Health Services. The main aim of the project was to monitor risk factors or determinants of chronic and infectious disease in the general population. Also studied were the differences with respect to many background- and health- related variables between participants interviewed at home and those taking the physical examination. Random sampling by the CBS led to home interviews by trained interviewers of individuals from the age of 0 who were willing to cooperate in the survey. The interview consisted of items related to aspects of health status and use of medicines/medical devices. Questions on lifestyle factors (smoking, drinking and vaccination) were included. At the end of the interview, participants were asked for permission to be approached for an additional health examination. Participants older than 12 years were asked to visit the nearest community or municipal health service (GGD). Of the participant, 60.9% agreed to participate in the additional health examination. A short physical examination was performed at the health centre. Blood samples were taken and blood pressure measured, as well as height, weight, and waist and hip circumferences. In addition, the 'joint-function test' was performed and an additional questionnaire was distributed. Of the people interviewed, 30.0% had visited the community or municipal health centre. The participants undergoing the physical examination were representative of the Dutch population, in that there were no major differences with respect to most of the background- and health-related variables between participants interviewed at home and those taking the physical examination. The prevalence of hypertension was 19% in men and 16% in women. The prevalence of overweight was higher for the women than for the men (12 % versus 9%). The estimation of overweight was different for length and weight (reported was higher than measured), clearly seen especially among the women. On the basis of non-fasting glucose measurements, 1.6% of the group had a high glucose level.<br>

To gain insight into the incidence and severity of pertussis in the Netherlands in 1999 and 2000, surveillance data based on notifications, laboratory data, hospitalisations and deaths were analysed for these two years and compared to the 1989-1998 period. Results of the paediatric surveillance are also presented here. According to various sources the incidence of pertussis increased in 1999 compared to previous years and decreased again in 2000. The peak incidence according to notifications and positive serology was observed among 4- to 5-year-old children. In 1999 the incidence according to hospital admissions (3.2 per 100,000) was comparable to the incidence during the epidemic of 1996 (3.3 per 100,000) and decreased in 2000 (1.6 per 100,000). The paediatric surveillance showed that most hospitalised children were under one year of age and that complications (apnoea, cyanosis and administration of oxygen) were more frequently reported in the younger age groups. Vaccine efficacy, estimated by the screening method, was higher in 2000 compared to 1997-1999, particularly among 1- and 2-year olds. In conclusion, the incidence of pertussis in 1999 according to notifications increased to reach a higher level than in 1996. In 2000 the incidence decreased again. However, the number of hospital admissions were comparable to the figures for 1996 and 1999, and lower in 2000. Both unvaccinated and vaccinated persons can develop classical pertussis symptoms. Surveillance of pertussis based on various surveillance sources should be continued to monitor the incidence of pertussis and to study the effect of changes in vaccination strategies. Active paediatric surveillance and surveillance of hospital admissions are useful for verifying trends in routine surveillance and describing the severity of pertussis.<br>

The Objective of the study was to determine the prevalence of HIV infection and the level of injecting and sexual risk behaviour, and to gain insight in the acquaintance with and the use of prevention activities. This study is part of a study on HIV prevalence and related risk behaviours among drug users in Rotterdam (end of 1994). Transvestites and transsexuals working in the street prostitution and reporting use of hormones or silicones were included in the original study. When this appeared to be a sizeable group, the questionnaire was extended with some specific questions. Saliva was collected from all participants and tested for antibodies to HIV-1/2. Participation was on voluntary basis and anonymous. All participants were biologically male. HIV prevalence among these participants showed to be low (8%). This finding contrasts with studies in other countries. In this study risk of HIV infection was not related to injecting drug use. Possibly, these transvestites and transsexuals are at risk for HIV infections through private or commercial sexual contacts with homo/bisexual men. Risk behaviour related to the use of needles for injecting hormones and/or silicones risk is low. Unprotected sexual intercourse with clients is rare, but occurs frequently with steady partners. Knowledge and use of AIDS prevention programmes are high.

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